Promising effect of a family rugby programme for children with ADHD: Promoting parent-child...

Complementary Therapies in Clinical Practice 39 (2020) 101135

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Promising effect of a family rugby programme for children with ADHD: Promoting parent-child relationship and perceptual change on child’s behaviors Angela FY. Siu a, *, Julia WK. Lo b a b

Dept of Educational Psychology, The Chinese University of Hong Kong, Shatin, NT, Hong Kong Dept of Social Work, The Chinese University of Hong Kong, Shatin, NT, Hong Kong

A R T I C L E I N F O

A B S T R A C T

Keywords: Attention Deficit Hyperactive Disorder (ADHD) Chinese families Family-based programmes Rugby Sports participation

Background and purpose: This study explored the effectiveness of a family-based rugby programme to improve the parent-child relationship for children with ADHD and their parents.

Materials and methods: A total of 17 Chinese families (12 fathers and 13 mothers) of children (in early primary grades) with ADHD participated in this study. Mixed methods, including questionnaires, parent focus groups, parental reflective journals, and interviews with children, were adopted.

Results: Quantitative data suggested a trend of parental perceptual change on their children’s ADHD behaviors.

Thematic analysis on the qualitative data further suggested the family rugby programme served as “a family play context” that helped promote parent-child relationship for the Chinese children with ADHD and their parents.

Participating children experienced “a different self” and better self-control when playing rugby.

Conclusion: There is a promising effect of the use of rugby as an alternative family-based approach for children with ADHD and their parents.

1. Introduction Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common childhood mental disorders in the world, with a pooled prev­ alence of 7.2% [1] and affecting 6.1% of school-aged children in Hong Kong [2]. The core features of ADHD are inattention, hyperactivity, and impulsivity, and the difficulties associated with ADHD can substantially interfere with the daily lives of children and their families [3].

Compared with their typically developing peers, children with ADHD often face more challenges in interpersonal relationships and academic learning [4,5]. These pervasive impairments in social and academic achievements can negatively affect the self-competence of children with ADHD [6,7] and induce other adverse effects, such as aggressive behaviors and symptoms of depression and anxiety [8–10].

This often resulted in persistent and negative developmental outcomes [11,12].

The parent-child relationship has been identified as a key family factor in nurturing the social, behavioral, and emotional development of children with ADHD [13]. A Western study has shown a strong rejection between the parent–child relationship and ADHD symptoms [14], and a

study in Hong Kong has revealed the significant role of the father-child relationship in supporting the development of perceived competence (self-perception) in children with ADHD [15]. Yet families raising a child with ADHD often have more conflictual family relationships, less organized communication, and less affective involvement than other typical families [16]. Many Chinese parents of children with ADHD experience a burden of care in managing everyday problems given the current daily parenting practices among Chinese cultures [17]. This may explain the high parental stress of Chinese fathers and mothers of chil­ dren with ADHD [18] and the lower quality of life of Chinese parents of children with ADHD compared with other parents in the general pop­ ulation [19]. Under this high level of psychological distress, parents of children with ADHD were reported to have less warmth and less involvement with their children [20]. This lack of warmth and lack of supportive parent–child interactions have been linked with aggressive behavioral problems in children [21], putting a strain on the paren­ t–child relationships of these families.

* Corresponding author.

E-mail address: afysiu@cuhk.edu.hk (A.FY. Siu). https://doi.org/10.1016/j.ctcp.2020.101135 Received 8 September 2019; Received in revised form 9 January 2020; Accepted 3 March 2020 Available online 5 March 2020 1744-3881/© 2020 Elsevier Ltd. All rights reserved.

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1.1. Lack of family leisure for Chinese families of children with ADHD in Hong Kong

connecting with their peers and following rules in sports [39]. However, there is a lack of studies on the potential benefits of organized sports as a type of family leisure activity for Chinese families of children with ADHD.

Chinese families of children with ADHD usually have little quality time to spend with family members [22], which can place family members under stress and hinder the parent–child relationship. These families often face barriers to accessing leisure facilities in the com­ munity [23]. Compared with typical families, families of children with ADHD are less likely to engage in family leisure activities because of the psychosocial disturbances of ADHD [24]. Parents of children with ADHD often feel socially discriminated against and face a lack of community resources to support the family as a whole [17]. There is a need for Chinese families of children with ADHD to enjoy quality time with their family members to promote the parent–child relationship of these families.

1.4. Rugby for Chinese children with ADHD and their families Rugby has been found beneficial for young people’s self-perception and prosocial behaviors [40,41], and is inclusive for teammates with mixed abilities [42]. Given its characteristics of physical power and physical contact, rugby may be useful for promoting active parent-child interactions and fostering family closeness. As a Western sport, rugby is generally a non-traditional leisure option for Chinese families. There­ fore, participation in rugby may offer novel experiences to Chinese families of children with ADHD and promote family adaptation to new challenges.

The present study aimed to look into the following three aspects: (a) How parents experience their involvement with their children in the rugby programme; (b) How children perceive themselves and their parents in the rugby programme; and (c) How the rugby programme contributed to novel experiences in parent-child interaction. It is anticipated rugby as a family leisure activity can be effective in enhancing ADHD children’s perception about self and to facilitate healthy development of parent-child communication and connection.

1.2. Family leisure and family functioning Family leisure involvement has been linked with various positive family outcomes, such as enhancing family cohesiveness and family adaptability [25], improving family communication [26], and improving young people’s emotional well-being [27]. Although most research on family leisure has focused on the general population (e.g.

Ref. [28]), some studies have explored families of children with devel­ opmental challenges. For instance, participation in family leisure has been found helpful in promoting the family functioning of families of children with developmental disabilities [29] and families of youth receiving mental health treatment [30]. In addition, Mitchell and Lashewicz [31] reported that leisure activities can benefit the father–­ child relationship and promote fathering among families of children with autism spectrum disorder.

According to the Core and Balance Model of Family Leisure Func­ tioning, the family system tends to actively seek a dynamic state of homeostasis in the leisure activity context [32]. Grounded in the family systems theory, the Core and Balance Model holds that when families are engaged in leisure activities, they can self-regulate and explore different mechanisms to maintain stability and adapt to changes, during which the family system constantly receives new inputs and new energy by interacting with family members and with the external environment [33]. The family functioning of these families can be promoted when the family system seeks to strike a balance between adapting to new situa­ tions and maintaining closeness [33]. According to this model, family leisure activities included two interrelated categories, namely core family leisure activities and balance family leisure activities. Core family leisure activities are activities that families can do frequently and are often home-based activities, such as playing board games and shooting a basketball [32]. In contrast, balance family leisure activities are activ­ ities usually conducted outside the home, such as boating and sporting events [32]. According to the model, core family leisure activities pro­ vide predictable family experiences that can be useful in promoting family closeness, while balance family leisure activities provide novel family experiences that can promote family adaptability to changes [33].

2. Materials and methods 2.1. Participants The present study is a pilot investigation on the use of rugby for helping Chinese families of children with ADHD, and there is no prior information upon which to base the sample size for this study. Hence, this study followed a general guideline for pilot study which recom­ mended a sample size of at least 12 participants per group [43]. Previous pilot investigations on play-based intervention for children with ADHD [44] and family-based intervention [45] also had a minimum of 12 participants or families included.

Seventeen families participated in this study. These included 14 children with ADHD (mean age ¼ 7.36, 4 girls and 10 boys), 12 fathers, and 13 mothers. Of these, 15 families were intact and 2 were singleparent families. All families participated in this programme on a voluntary basis. Ethics approval was granted by the University Ethics Committee for conducting the current research. Written consent was also obtained from parents of individual children before the start of the programme.

The inclusion criteria for the participants were: (a) Chinese families of school-aged children with ADHD (primary 2 or 3, i.e. aged between 7 and 8); (b) commitment to all sessions of the programme; and (c) parents who are mentally fit (i.e. no reported mental health issues and/or psy­ chiatric disorders).

2.2. Organization of the rugby programme The programme consisted of six consecutive weekly sessions of 1.5 h each. To encourage the involvement of the fathers who usually work on weekdays and Saturdays, the programme was held on Sunday mornings in a public natural turf field located in the city center, 30 min from most areas in Hong Kong.

Each session was structured in two parts: training in basic rugby skills for children and family rugby play. During the first hour of the session, the coaches trained the children in basic rugby techniques (such as delivering passes, running sideways and backwards, tackling in oneon-one situations) using various drills and cooperative games, while the parents observed how things were going in the field between the coaches and their children and between the children. After receiving basic knowledge and skills in rugby, the children actively invited their parents

1.3. Organized sports, children with ADHD, and Chinese families Organized sports are among the most common leisure activities for children outside the home in Hong Kong. Abundant research has demonstrated the positive effects of participation in organized sports for children with ADHD, including behavioral improvements, such as reducing disruptive behaviors [34,35], and psychological benefits, such as reducing symptoms of anxiety or depression [36,37].

In recent years, organized sports have assumed a new role in parenting to cultivate the parent-child relationship [38]. Recreational sport activities have been seen as a useful context for effective father involvement in supporting their children who may have difficulty in 2

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alphas exceeding 0.9 [47].

to join them in the field in the last 30 min of each session. The families were divided into three to four subgroups to continue practicing basic skills using group games, during which the children could share their learning with their parents.

All sessions were led by a team of coaches who are experienced in conducting inclusive rugby programmes. The main coaches were a fe­ male coach and a male coach. This combination was intended to set up a role model for the families regarding the inclusiveness of rugby to encourage the participation of all family participants in the game. A holistic coaching approach was used to enable the coaches to build a good relationship with each participating child through interpersonal communication. The coaches paid attention not only to the physical abilities of the children, but also to their emotional state, as it could affect their learning. The children were allowed to be rough, but also had to follow the rules in the field. The two main coaches were sup­ ported by two other coaches who helped oversee the entire process and support the children who needed individual attention.

2.3.1.2. Parents’ well-being. Parenting stress was assessed using the Body-Mind-Spirit Well-Being Inventory (BMSWBI [48]). BMSWBI serves as a multidimensional measure of holistic well-being by assessing in­ dividual’s attributes in additional to physical and mental health.

BMSWBI is a self-report instrument with 56 items consisting of four components: Physical Distress, Daily Functioning, Affect and Spiritual­ ity. A 10-point scale ranging from 0 to 10 for 26 positive items and from 10 to 0 for negative items is adopted, while the higher the total scores in BMSWBI indicates better quality of life. This instrument was developed and validated among Chinese adults in Hong Kong with the reliability ranged from 0.75 to 0.92 [48].

2.3.1.3. Parent-child interaction. The Parent-Child Interaction Ques­ tionnaire—Revised (PACHIQ-R [49]) was used to assess the quality of parent-child relationship. The PACHIQ-R comprises 21 items for the Parent version and is divided into two subscales as Conflict Resolution and Acceptance. For the items about prevalence of certain behavior and feeling, both parents and children were asked to categorize their re­ sponses into “never”, “hardly ever”, “sometimes”, “almost always” and “always”. For the items concerning the frequency at which certain behavior displays or actual felling, the five response categories vary from “it does not apply to me at all” to “apply to me exactly”. Both positive and negative statements are demonstrated in the scale (positive statement example: “I often have a laugh with my mother”; negative statement example: “My mother doesn’t understand me very well”), reverse coding for negative statement is necessary before summation of the item scores. The higher the total scores in the scale, the better the quality of relationship between child and parent is resulted. The reli­ ability of PRCHIQ-R is robust, and the internal consistency ranged from 0.75 to 0.95 in the subscales and the total scales in both the Parent and Child versions.

2.3. Measures This study adopted mixed method approach for data collection (Table 1). Approaches were: pre-post questionnaires for parents, parent focus groups, parental reflective journals, interview and drawing from individual children.

2.3.1. Questionnaire for parents at pre- and post-programme periods 2.3.1.1. Parental perception on Child’s ADHD behaviors. The Strengths and Weaknesses of ADHD-symptoms and Normal behavior (SWAN; [46]), was used to evaluate parents’ perspective on their child’s ADHD behaviors. A Chinese version of SWAN [47], which consists of 18 items measuring the full range of behavior in addition to the pathological signs and symptoms of ADHD, was adopted in the present study. Each item is a question phrasing with expected behavior of children. For example: “How does the child give close attention to detail and avoid careless mistakes?”. The SWAN scale is divided into two subscales, i.e. the sub­ scale of inattention (SWAN-I) and the subscale of hyper­ activity/impulsivity (SWAN-HI). Parents were asked to compare the child’s behavior with other children of the same age and score the items using a 7-point scale ranging from þ3 (far below average) to 3 (far above average), and a score of 0 (in the average) [46]. There is also a clinical cutoff point for each subscale. This Chinese version of SWAN was validated among Chinese children in Hong Kong with Cronbach’s

2.3.2. Parent focus groups (PFG) Two sessions of focus groups were conducted with parents one month after the end of the programme to see the sustainability of the positive impact of the programme for the families. Twenty parents from 12 families, including 9 fathers and 11 mothers, joined the focus groups.

A semi-structured interview guideline was adopted to explore parents’ subjective experience, including their perceived gains and benefits, the perceived useful characteristics of the program, and the sustainability of the positive effects, in participating in the programme. A semi-

Table 1 Participants’ profile.

Family

A1 A2 A3 A4 A8 A9 A10 A12 B1 B2 B3 B4 B6 B7 B8 B9 B10

Child name (pseudonym)

Joe Jenny Ben Christine Florence Zach Brian Charlotte Mark Raymond Joy Jacky Charles Andy Benjamin Hayman Kenny

age/gender

9/M 7/F 8/M 8/F 7/F 7/M 7/M 7/F 8/M 8/M 7/F 7/M 7/M 8/M 7/M 7/M 7/M

Child (N¼17)

Father (N¼15)

Mother (N¼17)

CII (n¼14)

CD (n¼10)

PRJ (n¼7)

PFG (n¼9)

PRJ (n¼10)

PFG (n¼11)

0 1 1 1 0 1 1 1 1 1 1 1 0 1 1 1 1

0 1 0 1 0 0 1 1 0 1 1 1 0 0 1 1 1

1 1 1 0 0 1 1 0 0 0 0 0 1 0 0 0 1

0 1 1 / 0 0 1 1 1 1 0 1 0 / 1 0 1

1 1 1 1 1 0 0 0 1 1 1 1 0 0 0 0 1

0 1 1 1 0 0 1 0 1 1 1 1 0 1 1 0 1

Notes: CII¼ Child Individual Interview; CD¼Children’s drawing; PRJ¼ Parental Reflective Journal; and PFG¼Parent Focus Group 3

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structured approach was chosen so that interviewers can learn answers to questions and the reasons behind the answers. The interviews were conducted by an experienced family therapist who had little involve­ ment with the families during the programme. Each focus group lasted for about an hour.

3. Results 3.1. Quantitative results Results from the quantitative data on ADHD symptoms, parent-child interaction and parents’ well being indicated no significant changes between pre and post programme. However, as shown in Table 2, it was worth-noting that parents’ views on child’s ADHD symptoms (as re­ ported in the subscale relating to “Inattention”) indicated a tendency of pre-post difference towards a significant level at 0.05 though the decreased scores have not reached the clinical cut-off point. Even so, this may indicate a trend in the change of viewing child’s ADHD symptoms (on inattentiveness). Parents tended to view their children’s behavior as more “typical” when compared to the time before they joined the programme.

2.3.3. Parental reflective journals To explore the parents’ experience throughout the process, a parental reflective journal was designed with reference to Slade’s study [50]. At the beginning of the first session, parents were asked to make observations on their children and on themselves about their feelings, thoughts, beliefs, desires, and intentions throughout the programme. At the end of the last session, each participating parent was given a worksheet to answer two questions: “describe your child throughout the programme” and “describe yourself throughout the programme.” The parents were advised to complete the journal within a week after the last session. Seventeen parents from 13 families, including 7 fathers and 11 mothers, completed and returned their journals.

3.2. Qualitative results Three main themes were identified from the interview data: “a family play context,” “feeling safe to express oneself freely,” and “a different self”.

The results are summarized in Table 3.

2.3.4. Individual interviews with children and children’s drawings Individual interviews with the children were conducted to explore the participatory experience of children with ADHD. Following a semistructured interview guideline, children were asked whether they liked the programme and what they liked about it, how they perceived themselves and their parents in the field, and the perceived sustain­ ability of the positive effects. A total of 14 children were interviewed by two interviewers experienced in working with children with ADHD. To access the children’s perspective and promote the articulation of their experience, children’s drawing was adopted as a method of data collection in the study. Previous studies have shown that the use of drawings in interviews with children has practical advantages for engaging children, because of the fun and non-threatening characteris­ tics of drawings [51] and their reduced requirements for proficiency in literacy and verbal skills [52]. During individual interviews, the chil­ dren were asked to draw on a piece of A4-sized paper to represent their experience of playing rugby in the programme. Among the 14 children interviewed, 10 drew a picture during their interview. The two in­ terviewers also came to the field, but had little involvement with the children. Each interview lasted between 10 and 20 min.

3.2.1. A family play context Many of the participating parents and children described the rugby program as a time for “family play.” Both parents and children treasured this opportunity to play together on the rugby field. The families revealed that this program was a common goal for both parents and children on Sundays, which motivated the children to wake up early to pack and join the sessions on time. Many participating parents felt a greater sense of intimacy with their children after playing with them Table 2 Mean difference of Parental perception on ADHD behaviors, Parent-child interaction and Parents’ well-being.

2.3.5. Data analysis 2.3.5.1. Quantitative analysis. Student’s t-tests were employed to examine whether there was any significant change in parental percep­ tion on their children’s ADHD behaviors, parents’ well-being and parent-child interaction after participation in the family rugby pro­ gramme. SPSS (version 25) was adopted.

2.3.5.2. Qualitative analysis. The interviews were recorded and tran­ scribed verbatim. Pseudonyms were used to ensure confidentiality.

Following the step-by-step guideline of the thematic analysis proposed

by Braun and Clarke [53], the authors first reviewed all of the data sentence by sentence to become familiar with the data. Then, the initial codes were generated by systematically encoding different features of the data in the dataset. The potential themes and sub-themes of the research topic were then identified by collating the codes. Finally, all potential themes were counter-checked with the coded extracts and the dataset, through which an ongoing analysis was performed to refine the naming of the themes until a clear definition was developed for each theme.

Pre-test

Post-test

Paired-t

Parental perception on ADHD behaviour

Mean (SD)

Mean (SD)

t-value (p)

Effect size

Combined behavior (SWAN) Inattention (SWAN-I)

1.09(0.67)

0.82(0.78)

0.42

1.22(0.63)

0.80(0.89)

Hyperactivity/Impulsivity (SWAN-HI)

0.96(0.93)

0.84(0.83)

1.62 (0.13) 1.99 (0.067) 0.62 (0.55)

Parent-child interaction

Total score (SD)

Total score (SD)

t-value (p)

Effect size

Combined interaction (PACHIQ-R) Conflict resolution (PACHIQ-C) Acceptance (PACHIQ-A)

70.2(6.30)

72.1(4.59)

-0.34

42.5(3.33)

43.1(2.87)

27.7(4.89)

28.9(2.99)

-1.08 (0.30) -0.65 (0.53) -0.95 (0.36)

Parent’s well-being

Mean (SD)

Mean (SD)

t-value (p)

Effect size

Overall well-being (BMSWBI) Body

3.95(1.08)

4.06(0.93)

-0.28

2.35(1.63)

2.03(1.58)

Mind

5.52(1.89)

5.82(1.85)

Spirit

4.19(1.70)

4.09(1.34)

Well-being

4.27(1.29)

4.55(0.95)

-0.69 (0.50) 1.41 (0.18) -0.85 (0.41) 0.49 (0.63) -1.26 (0.23)

0.54 0.27

-0.21 -0.30

0.15 -0.32 -0.18 -0.48

Notes. SWAN: The Strengths and Weaknesses of ADHD Symptoms and Normal Behavior questionnaire (C¼Combined; I¼Inattention; HI¼Hyperactivity).

PACHIQ: The Parent-Child Interaction Questionnaire-Revised. BMSWBI: The Body-Mind-Spirit Well-Being Inventory.

4

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breadwinners of the families, and they usually spent their Sundays at home to rest instead of spending time with their family. The mothers and children were thrilled to experience an active father on the rugby field.

Some fathers also realized the importance of their involvement in parent–child play. From the family participants’ perspective, the rugby programme offered a joyful and engaging context for fathering.

Table 3 Summary of major themes and subthemes.

Themes

Sub-themes

1 A family play context

1.1 Unique characteristics of Rugby 1.2 Father involvement 1.3 Having fun is our only goal 2.1 Not being blamed for the misbehaviors of their children 2.2 Coaches with accepting attitude 2.3 He fell, but it’s alright!

3.1 Better self-control

2 Feeling safe to express oneself freely 3 A different self

“I am amazed! Their father rarely joins his daughters’ activities as he needs to work. This programme was very good in that it allowed my younger daughter and her father to interact more and talk more, and I can see they have better interactions and better communication. I saw a very different side of him [husband] in the field” (A2-mother, PFG).

regularly.

“What I found special about this program is that the four of us could play together … We had previously organized different sports pro­ grams or outdoor activities for our children, but we usually partici­ pated in the training individually. This was a valuable opportunity for our family to share a moment together in the field” (A3-father, PFG).

“My father doesn’t like to exercise on normal days. I went to the playground two days ago and I asked him to play with me, but he said, ‘let me rest for 10 more minutes.’ After 10 minutes, he asked for 5 more minutes. (How about your father in the field?) He said, ‘Okay!

I will join you after drinking some water!’ And he joined immedi­ ately!” (A12-child, CII)

“[I] started getting used to rugby training every Sunday. After spending more time with my daughter, I noticed the improvement of our relationship” (A8-mother, PRJ).

“At the beginning of the program, I thought this was a typical parent–child activity. Until I noticed that my son seemed especially happy when I played with him. I realized that I should have more activities with him, which should be a good thing for both of us” (B10-father, PRJ).

One father used the metaphor of “herding the sheep” (B10-father, PFG) to describe his family’s usual practice of leisure activities, illus­ trating his passive parental involvement in these activities. In stark contrast to this passivity, “family play” in the rugby program was characterized by activeness, fairness, and connectedness between family members in the field. Three aspects of the rugby program were found to relate to this family play context for the participating Chinese children with ADHD and their parents.

3.2.1.3. Having fun is our only goal. In most other family leisure or sports activities, the parents usually expected their children to acquire new knowledge or skills. It was common for these parents to set a goal for their children in these leisure activities. Both fathers and mothers mentioned that the rugby programme allowed them to play an alter­ native role and get along with their children. They treasured this alternative practice of parenting by playing freely and happily with their children, without worrying about cognitive or behavioral gains.

3.2.1.1. Unique characteristics of rugby. Sports and outdoor activities were the common options chosen by the participating parents to release the high energy level of their children with ADHD. The participating fathers particularly appreciated the simple and easy-to-follow rules of rugby, which encouraged all family members to join the game. The inclusiveness of rugby helped the parents and the children enjoy family play regardless of differences in physical abilities.

“To be honest, you won’t enjoy this programme if you are concerned about learning skills. The purpose of this game is to play together.”

(B1-father, PFG).

“I feel that I was like a boss when I took care of my son on normal days. But in the field, we were not parents. We were playmates!” (B1mother, PFG)

“Rugby is easy to play and anyone can do it … unlike soccer or basketball, which require more advanced skills” (B1-father, PFG).

“It was different this time. I did not assign any tasks to my son in the game because the coaches told us to do the same thing together. If I was the one who gave the order, my son would not have enjoyed playing with us” (B2-mother, PFG).

In addition, both parents and children recognized that the freedom to run on the natural turf and the physical contact of the game were the main contributors to their enjoyment when playing rugby. This was a rare experience on normal days.

“They enjoyed it a lot! They talked about what they did during training after going home. Children in Hong Kong, boys and girls alike, tend to be repressed by rules in different places for example at school. But this activity let them run … tackle … throw the ball … it could be a kind of stress relief for these children” (A2-mother, PFG).

3.2.2. Feeling safe to express oneself freely The second theme that emerged from the interview data was “feeling safe to express oneself freely.” This theme was mainly derived from the parents’ experience. From the parents’ perspective, the rugby pro­ gramme helped create a sense of security. This sense of security helped them feel relieved, calm when facing problems, and allowed them to enjoy playing with their children. Three aspects of the rugby programme were found to be related to this feeling of psychological safety among participating parents.

“Another advantage of rugby for children with ADHD was that it allowed physical contact … other sports activities don’t allow it” (B8-father, PFG). “(There is also playtime at school … what’s the difference?) I was much more excited here! I could run freely and wouldn’t be punished as often as I am at school. It is not allowed to run at school” (B4-child, CII).

3.2.2.1. Not being blamed for the misbehavior of their children. Discussing previous experiences, the parents mentioned being discriminated against and stigmatized in other sports or leisure activity classes for all children. When these children joined other sport games it was usually difficult for them to follow the rules and cooperate with other children in these classes. What ended up would be the case that their children were often removed from the classes, bullied by their classmates, or had conflict with others. Other parents might also see these children as

3.2.1.2. Father involvement. Many participating mothers appreciated that the rugby programme successfully engaged the fathers to actively participate in parent–child play. The fathers were usually the 5

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Complementary Therapies in Clinical Practice 39 (2020) 101135

“problematic” and “bringing in troubles all the time”. The parents appreciated that this rugby programme was exclusively for families with similar difficulties. This similarity among participating families pro­ moted empathy between the parents and helped them be less conscious of their children’s deviant behavior, which in turn allowed them and their children to enjoy the process.

into a powerful energy that drove him to run faster and jump higher in the game.

“I found myself more animated here [the field] than other days!

There are too many rules I need to remember outside the field. But here [the field], I could forget everything. (What’s so special about this?) I was happier and more relaxed when I could forget the troubles of other days” (A12-child, CII).

“I am usually stressed when my son is involved in other sports or leisure activities. ‘Why were you so excited and impetuous again?’

My son often had conflicts with his peers and I was so worried that he would hurt someone. But I could relax here as we all knew these children. I saw that my son really enjoyed the game when he was not being watched for misbehavior” (B7-mother, PFG).

“I found myself less angry on the field compared with other days. I was not easily angry at others when I was in the field. I could control myself better, maybe because I could focus on playing rugby while ignoring the negative comments of others” (B2-child, CII).

4. Discussion

3.2.2.2. Coaches with accepting attitudes. The parents indicated that the coaches in this rugby programme were very different from those in typical sports classes, in that they focused more on engaging the children to play rugby instead of training them to acquire skills. As described by the parents, the coaches in this programme understood the needs and characteristics of the children and were very accepting.

The results of this exploratory study suggested that the rugby pro­ gramme could be a family-based programme for families of children with ADHD. It not only provided a space for quality family time, but enriched the parent–child relationship of families of children with ADHD because of its family play context and to encourage family adaptation to challenges because of its supportive and safe environment.

Results also revealed that the rugby with families is a promising pro­ gramme and provides useful context to promote children’s self-control and parental perceptual change on the ADHD behaviors.

The results of the study shed light on the importance of parent-child physical play in improving the parent–child relationship among families of children with ADHD. The rugby programme fostered a play context rather than a caregiving context for the parents and children with ADHD. The parents and their children became playmates in this play context, which reduced the parent–child hierarchy and fostered mutual responsiveness between parent–child dyads. This result is consistent with a previous study of the general public conducted by Lindsey and colleagues [54], indicating that a play context can induce greater parent–child mutuality and a higher level of positive emotions in dyads.

In addition to the positive effects of the family play context, the orga­ nization of the rugby programme (i.e. the children in the field for the first part, then the parents and the children in the field for the second part) also contributed to fostering mutuality between Chinese children with ADHD and their parents. We noticed that children enjoyed the first part of the game and were excited about inviting their parents to join them and share the joy with them. The organization of the rugby pro­ gramme was helpful in promoting more positive interaction between parent and child dyads. Further studies are needed to look into the effectiveness of the rugby programme in promoting positive parent-child interaction for children with ADHD and their parents who suffer from tense and conflictual relationships. The lessons learnt in this programme may also be applied to other sports upon further exploration.

The results of this study also showed that the rugby programme promoted father–child play in family leisure activities. Unlike moth­ er–child play, whose main purpose is protection and comfort, father–­ child play encourages children’s exploration and adaptation to the external environment [55]. Father–child physical play in the form of rough-and-tumble play has been found to be beneficial for the psycho­ social adjustment of children, such as emotional regulation [56], and the development of social competence [57]. Conversely, the quality of the father–child relationship during play has been found to moderate the associations between father–child vigorous play and its positive effects on children [58]. Rugby play in the programme characterized by vigorous behaviors, such as grappling, tumbling, and running, offered a safe and playful context for father–child play, similar to that of rough-and-tumble play. The results of the study revealed that vigorous father–child play on the rugby field helped promote father–child in­ timacy. However, it remains unclear how father–child rugby play may contribute to the psychosocial adjustment of children with ADHD.

“When the children ran off the field, the coaches would not stop them immediately, but allowed them to play freely for a while. After that, the coaches would talk to them and the children would return to the field!” (A2-father, PFG) In addition, parental observation during the first hour of each session was found to encourage parental reflection. One father stated that observing how the coaches handled the children prompted him to reflect on his parenting practice.

“After watching how the coaches coached the children, I noticed that I scolded my children less. In the past, I used to shout at my son immediately if I found him doing something wrong. But now, I usually wait for a while before I talk to him” (A3-father, PFG).

3.2.2.3. He fell, But It’s All Right!. One of the most impressive moments for the parents was the session conducted in the pouring rain. The parents were surprised that their children remained committed to coming to the field even in bad weather. Being part of a supportive and trustful network, the parents became more open to let their children explore, fall, and lose in the field, which in turn enabled the children to face challenges in a psychologically safe environment.

“In fact, I was worried that he would get sick after playing in the rain.

But when I saw that he wanted to join the class even on a rainy day, I let him as long as he was okay to go on” (B2-mother, PFG).

“Even if my son was pushed to the ground, it was okay as long as it was not a serious fight. He just had to get up and continue. It was not a big deal.” (B8-father, PFG).

3.2.3. A different self The third theme identified from the interview data was “a different self,” which was derived primarily from the children’s experience. When asked whether they saw themselves as different in the programme, many children perceived themselves to have a better emotional regulation when they played rugby in the field.

3.2.3.1. Better self-control. The children indicated that they felt happier, less impulsive, and more focused when running freely on the natural turf, which they could not do on other days. The free environment of the field fostered positive emotions in the children, which helped them ignore the things that provoked them in favor of focusing on playing rugby. One boy (A10-child, CII) explained that having to stay focused on the rugby game helped him turn his negative emotions, such as anger, 6

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Complementary Therapies in Clinical Practice 39 (2020) 101135

Further studies are needed to investigate the role of father–child rugby play in the psychosocial development of children with ADHD. In this study, Chinese children with ADHD expressed a strong intrinsic interest in playing rugby with their parents, contradicting previous studies suggesting that children with ADHD usually have negative feelings about physical activity because of their lower abilities in sports and lower movement skills than their peers [59,60]. The strong motivation of Chinese children with ADHD to engage in the rugby programme may be related to the intrinsic rewarding qualities of the game (i.e.the fun [61]) and the inclusion of playmates (i.e. peers with ADHD [62]). In addition, the results of this study showed that the children with ADHD had a positive experience of themselves when playing rugby. Future studies should further investigate the links be­ tween the characteristics of ADHD, rugby, and the social context of rugby play, and how they may be related to the self-concept of Chinese children with ADHD. A recent study has highlighted the significant role of sports coaches in creating a supportive environment for socially vulnerable children to enjoy meaningful sports experiences [63]. In line with this study, the results of the current study revealed that the coaches of the programme created a motivational climate for the children with ADHD and their parents by showing a strong acceptance of these children. Given that coaching is a complex social process involving interactive relationships between the coach, the players, and the context of the sports activity [64], it is important to better understand the coaching knowledge and practice of the family rugby context for children with ADHD and their parents.

It has been argued that the service options provided in Hong Kong to meet the diverse development needs of people with ADHD are inade­ quate [65]. The results of this study provided preliminary evidence supporting an alternative model using rugby as a family leisure activity for families of children with ADHD to enrich family relationships.

However, the results of the study also revealed some of the obstacles faced by these families to maintain the regular practice of this family leisure activity (i.e. lack of a circle of friends, low motivation of parents to organize activities in their own family). Therefore, further in­ vestigations on the service model and its development are needed.

5. Conclusion This study is the first attempt to use rugby as a family leisure activity for families of children with ADHD. The participating families perceived the programme to be helpful in enriching their parent–child relation­ ship. The rugby programme of the study was characterized by a family play context and psychological safety. The participating children had better self-control when playing rugby. Results of this study also sug­ gested that this family rugby programme is likely to be helpful in pro­ moting a perceptual change on ADHD behaviors among the parents after their participation. However, the families were unable to maintain the positive effects of the programme and wanted community building to consolidate these effects.

Declaration of competing interest Siu, A.F.Y., None; Lo, J. W.K., None.

Acknowledgement The authors would like to thank the Hong Kong Rugby Union (HKRU) for their generous support in sponsoring the coaches for working on this project and reserving the field for rugby games with all the ADHD families.

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4.1. Limitations of the study This study has several major limitations which worth considering when interpreting the findings. First, with a small sample size as well as its exploratory nature, the results of this study lacked generalizability and should be interpreted carefully. Second, the quality of the data may be affected by sampling bias because of the use of convenience sampling to recruit family participants from the community. There may also be parental bias in responding to the questions in the interviews as par­ ticipants knew very well the purposes of the programme. They may only give favorable answers to the questions. As parents of children with ADHD are more likely to have marital problems than other parents [3], high paternal and maternal participation in the programme may indi­ cate that the data collected may be distorted by other family variables.

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